Republic of the Philippines)

Province of__________________) S.S.

City/Municipality of________)
x---------------------------------------/

AFFIDAVIT OF LOSS

I,_____________, Filipino, of legal age,(single / married /

widow),and a resident of_____________, Philippines, after
being duly sworn in accordance with law, depose and state:

That I am the registered owner of a certain motor vehicle,

which is more particularly described as follows:

Make:_____________
Series:_____________
Type of Body:_________
Motor No.____________
Chassis No.___________
Yr. Model_____________
Color_____________
Plate No.____________

That as a registered owner, I was issued a

Certificate of Registration (C.R.) and an Original Receipt
(O.R.) for my registration for the year_______by the Land
Transportation Officeof_____________City, Philippines;

That when I was about to register the said motor

vehicle for year_________, I could no longer find said
Certificate of Registration and Official Receipt of the said
motor vehicle.

That despite diligent search and efforts to locate the

said documents, I could no longer find the same such that I
believe that they are now lost beyond recovery.

As such, I am executing this Affidavit of Loss to attest to

the truth of the foregoing and to support my application for
the issuance of new Certificate of Registration and Original
Receipt, in lieu of the ones that were lost.

IN WITNESS WHEREOF, I have hereunto set my hand

this_____________in the City of___________, Philippines.

JURAT

SUBSCRIBED AND SWORN TO BEFORE ME this ___ day

of __________, 2017, Affiant personally presented to me his
___________ ID as valid and competent proof of his identity.

Doc. No. _____:

Page No. _____;
Book No. _____:
Series of 2017.